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Medical Policy: 02.02.05
Original Effective Date: August 2000
Reviewed: August 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Signal averaged electrocardiogram (AECG) is a non-invasive way of identifying risks for potentially fatal heart rhythm problems. The procedure involves obtaining electrocardiograph signals from the heart, amplifying them, and then filtering and averaging them by computer. The procedure may detect "late potentials," low amplitude signals associated with serious rhythm abnormalities, which can lead to sudden cardiac death.
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Prior Approval:
Not applicable
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Policy:
Signal averaged ECG is considered investigational.
Data are inadequate to evaluate the impact on patient management SAECG including, but not limited to, its use in patients with cardiomyopathy; assessment of success after surgery for arrhythmia; detection of acute rejection of heart transplants; assessment of efficacy of antiarrhythmic drug therapy; assessment of success of pharmacological, mechanical, or surgical interventions to restore coronary artery blood flow; or risk stratification of patients with Brugada syndrome. Regarding the use SAECG to identify patients with syncope who may have inducible ventricular tachycardia, even though and American College of Cardiology consensus document published in 1996 concluded that SAECG had an established tole, data within that report reported only modest sensitivity (73%) and poor predictive values. Thus, if used to determine who should have electrophysiologic studies, the test would fail to detect many patients who have positive electrophysiologic studies.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 93278 signal averaged electrocardiography (SAECG) with or without ECG. For interpretation and report, use 93278 with modifier -26.
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Selected References:
- US Department of Health and Human Services. Health Technology Assessment. Number 11. Signal-averaged electrocardiography. 1988. Publication No. PB98-137227.
- Hohnloser, S.H., Klingenheben, T., Zabel, M. Identification of patients after myocardial infarction at risk of life-threatening arrhythmias. European Heart Journal 1999; 1(suppl C): C11-C20.
- Toubol, P. A decade of clinical trials; CAST to AVID. European heart Journal 1999; 1(suppl C):C2-C10.
- Julian, D.G., Camm, A.J., Rangin, G., et al, and the European Myocardial Infarct Amiodarone Trial Investigators. Randomized trial effect of amiodarone on mortality in patients with left ventricular dysfunction after recent myocardial infarction. Lancet 1997; 439:667-74.
- Cairns, J.A., Connolly, S.J., Rovert, R., Gent, M. Randomized trial of outcome after myocardial infarction in-patients with frequent or repetitive ventricular premature depolarization. Lancet 1997; 349-675-82.
- Moss, A.J., Hall, W.J., Canon, D.S., et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. NEJM 1996; 335:1933-40.
- Bigger, J.T. Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary artery bypass graft surgery. NEJM 1997; 337:1569-75.
- Gregoratos, G., Cheitlin, M.D., Conill, A., et al. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices; A report of the American college of Cardiology/American Heart Association Task Force on Practice Guidelines Committee on Pacemaker Implantation. Journal of American College of Cardiology 1998; 31:1175-1209.
- Klein, H., Auricchioa, Reek, S., Geller, C. New primary prevention trials of sudden cardiac death in patients with left ventricular dysfunction. American Journal of Cardiology 1999; 83:91D-97D.
- ECRI Institute. Signal-Averaged Electrocardiographs for Patients after Myocardial Infarction. Plymouth Meeting (PA): ECRI Institute; 2009 Oct 2. 8 p. [ECRI hotline response]. Also available: http://www.ecri.org.
- Cain ME, Anderson JL, Amsdorf MF et al. ACC expert consensus document. Signal-averaged electrocardiography. J Am Coll Cardiol 1996;27(1):238-49.
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Policy History:
Date Reason Action
August 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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